165
Enrollment Form
NC 457b DEFERRED COMPENSATION PLAN
print using blue or black ink. Please keep a copy for your records and send completed form to the following
Instructions Please
address or fax it to 1-866-439-8602.
Questions?
NC Plans Processing Center
PO Box 5340
Scranton, PA 18505
About
You
Plan number
Call 1-866-627-5267
for assistance.
Who is your employer?
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What Department do you work in?
________________________
________________________
(Please print entire employer name)
(Please print entire department name)
Have you recently changed employers?  Yes
 No
Previous Employer Name: ________________________
Social Security number
Daytime telephone number
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First name
MI
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area code
Last name
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Address
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City
State
ZIP code
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Email address
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Date of birth
Gender
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month
Contribution 
Information
day
year
Date of hire
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month
day
year
Before-Tax Contribution Election.
 $└──┴──┴──┘,└──┴──┴──┘.00 (please provide whole dollars only)
OR
 └──┴──┴──┘ % (please fill in % from 1-100%, in whole percentages)

Roth After-Tax 457 Contribution Election.
 $└──┴──┴──┘,└──┴──┴──┘.00 (please provide whole dollars only)
OR
 └──┴──┴──┘ % (please fill in % from 1-100%, in whole percentages)
My annual salary is $____________. My pay frequency is __________. Please note that if the contribution amount
provided is not in the correct format (dollar vs. percentage), Prudential will use your salary information to calculate your
contribution in accordance with what your payroll requires.
Ed. 4/2011 Percent & Dollar amount
Important information and signature is required on the following pages.
The signature page must be provided in order for your enrollment to be processed.
Investment
Allocation
(Please fill
out Part I, II
or Part III.
Do not fill
out more
than one
section.)
OR
OR
By completing one of these sections, you enroll in GoalMaker , Prudential’s asset allocation program, and you direct
Prudential to invest your contribution(s) according to a GoalMaker model portfolio that is based on your risk tolerance
and time horizon. You also direct Prudential to automatically rebalance your account according to the model portfolio
chosen upon enrollment and on a quarterly basis. Enrollment in GoalMaker can be canceled or changed at anytime.
Part I GoalMaker with Automatic Age Adjustment:
 Conservative
 Moderate
 Aggressive
Choose Your Risk Tolerance
GoalMaker also automatically adjusts your allocations over time based on your current age and the expected retirement
age. To ensure that your allocations are updated correctly please confirm your expected retirement age below. If an
Expected Retirement Age is not provided, age 65 will be used.
Expected Retirement Age: └──┴──┘
Part II GoalMaker without Automatic Age Adjustment
By completing this section, I confirm that I do not want to take advantage of GoalMaker’s Age-Adjustment Feature.
Please invest my contributions according to the model portfolios selected below.
Please refer to the Retirement Workbook for more information.
GoalMaker without Automatic Age Adjustment:
GoalMaker Model Portfolio (check one box only)
Time Horizon
Conservative
Moderate
Aggressive
0 to 5 Years to retirement
 C01
 M01
 R01
 C02
 M02
 R02
6 to 10 Years to retirement
 C03
 M03
 R03
11 to 15 Years to retirement
 C04
 M04
 R04
16 Plus Years to retirement
Part III Design your own investment allocation:
Please designate the percentage of your contribution to be invested in each of the available investment options. (Please
use whole percentages. The total must equal 100%.)
I wish to allocate my contributions to the Plan as follows:
Percent
Allocated
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Codes Investment Options
NC
YA
YK
YG
YH
YF
YE
YD
YB
YI
YC
YJ
North Carolina Stable Value Fund - 457 Plan
NC Fixed Income Fund
NC Fixed Income Index Fund
NC Large Cap Value
NC Large Cap Index
NC Large Cap Growth
NC Small Mid Cap Value
NC Small Mid Cap Index
NC Small Mid Cap Growth
NC International Index
NC International
NC Global Equity
1 0 0 % Total
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This form must be completed accurately and received by Prudential Retirement before Prudential Retirement receives
contributions on your behalf. If a completed form is not received, Prudential will invest contributions in the Plan’s default
investment option. Upon receipt of your completed enrollment form, all future contributions will be allocated according
to your investment selection. You may contact Prudential Retirement to transfer any existing funds from the default
investment option to any other fund(s) in the plan.
Important information and signature is required on the following page.
The signature page must be provided in order for your enrollment to be processed.
Social Security Number_______________________
I designate the following as beneficiary of my account with regard to the percentage(s) I have indicated below. Please list
Your
additional
beneficiaries, along with percentages they are to receive on a separate page, if needed. Indicate whether the
Beneficiary
additional beneficiary(ies) is/are primary or secondary beneficiary(ies).
Designation
(A) Primary Beneficiary(ies)
(B) Secondary Beneficiary(ies)
FULL LEGAL NAME
FULL LEGAL NAME
Address
Address
City
State
Social Security number
ZIP code
Percentage
City
%
My
Relationship
Date of birth
State
Social Security number
Address
Address
Social Security number
Date of birth
ZIP code
Percentage
City
%
My
Relationship
Please use whole percentages - must total 100%.
%
My
Relationship
FULL LEGAL NAME
State
Percentage
Date of birth
FULL LEGAL NAME
City
ZIP code
State
Social Security number
ZIP code
Percentage
%
My
Relationship
Date of birth
Please use whole percentages - must total 100%.
I direct my employer to make payroll deductions as I have indicated. I understand that upon enrollment, I will have
Your
telephone and/or internet privileges to perform transactions via Prudential's Interactive Voice Response service and
Authorization Online Retirement Center.
This section
must be
completed in
order to
process your
enrollment.
I agree that Prudential Retirement, the Plan’s trustees or the state of North Carolina will not be liable for any loss,
liability, cost or expense for implementing my instructions via the Internet or by telephone. I understand that Prudential
Retirement will execute on my instructions only when proper identification is simultaneously provided. This identification
may consist of information that Prudential Retirement may reasonably deem necessary to establish my identity. I hereby
give Prudential Retirement the right to tape record the telephone conversation of any telephone instructions received by
Prudential Retirement.
X
Participant’s signature
Social Security Number_______________________
Date